EM112.151127
Disaster Recovery Allowance
South Australia Pinery Bushfire November 2015
Go to next question
Your Centrelink Reference Number (if known) Do you have a Centrelink Reference Number?
5
No Yes
Go to next question
You may not be eligible for this assistance.
Please call us on 180 22 66.
Are you receiving an income support payment or pension (e.g. Age Pension, Newstart Allowance, Service Pension from the Department of Veterans’ Affairs or Farm Household Allowance)?
6
No Yes
Do any of the following apply to you?
7
Go to next question A permanent visa holder
Tick the first option that applies to you
Go to next question A New Zealand passport holder
Go to next question Holder of an
eligible temporary visa
None of the above You may not be eligible for this assistance.
Please call us on 180 22 66.
Refer to the factsheet for a list of eligible temporary visa classes.
Do any of the following apply to you?
8
Tick ALL that apply Suburb Live in an affected area
None of the above You may not be eligible for this assistance.
Please call us on 180 22 66.
Suburb Work in the affected area
Suburb Derive income from the
affected area
Have you lost or suffered a reduction in your income as a direct result of the disaster?
9
Go to next question
You may not be eligible for this assistance.
Please call us on 180 22 66.
No Yes
Are you 22 years of age or older?
10
Go to next question No
Yes Go to 15 Do you need an interpreter when dealing with us?
2
Go to 5 No
Yes Go to next question
This includes an interpreter for people who have a hearing or speech impairment.
To speak to us in languages other than English, call 131 202.
What is your preferred spoken language?
3
What is your preferred written language?
4
Go to next question An Australian citizen
1
Please read this before answering the following questions.The Disaster Recovery Allowance is for people who can demonstrate they have experienced a loss of income as a direct result of a disaster.
The Australian Government Department of Human Services will do regulare audits and you may be asked to provide evidence to support your claim.
For more information
If you are not sure about your claim, or you need more information, including details about the date you need to lodge your claim by, if you will be required to provide documentation to confirm your identity, or other assistance you may be entitled to, please refer to www.humanservices.gov.au/disaster or call us on 180 22 66.
CLK0EM112 151127
Your name
Other Family name
15
First given name
Second given name
Ms Miss
Mrs Mr
Your principal place of residence
Postcode Your date of birth
18
/ /
Go to next question No
Have you ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)?
16
Other name
Type of name (e.g. name at birth) Give details below
If you have more than 1 other name, attach a separate sheet with details.
Yes
Please read this before answering the following questions.
Questions 11–14 are to be completed ONLY if you are under 22 years of age.
Are you a parent or have a dependent child in your care?
11
Go to next question No
Yes Go to 15
What is your estimated income for the current financial year?
12
$
Are you wholly or substantially dependent on another person?
13
No Yes
You are classed as wholly or substantially dependent if you are dependent on another person (except your partner), are not the parent of another person and your income this financial year will be less than $6,403.
Are you currently living with your parent(s) or guardian(s)?
14
No Yes
Your gender
17
Male Female
19
What date did you start living at this address?
Was this your principal place of residence during the disaster?
Go to next question No
Go to 24 Yes
What was your principal place of residence during the disaster?
Postcode
22
/ /
When did you live at this address?
From
/ /
To
/ /
Postcode
Temporary address Postal address
Tick ONE box only
Do you have a temporary or postal address?
Go to next question No
Give details below Yes
What date did you start living at the address given at 24?
This address is:
Go to next question Go to 26
/ /
20
21
23
24
25
EM112.151127
Your visa details on arrival
34
Date visa granted Visa sub class
/ /
Phone number ( )
Mobile phone number
Note: This mobile number will automatically be subscribed to our electronic messaging service. We may use this mobile number to contact you. For Terms and Conditions, go to www.
humanservices.gov.au/em
To help us serve you better, please provide your mobile number How can we contact you?
26
Were you in Australia when the disaster occurred?
27
Go to next question No
Go to 29 Yes
When did you return to Australia after the disaster?
28
/ /
Are you living in Australia permanently?
No Yes
Australia
Are you an Australian citizen who was born in Australia?
30
Country of citizenship Other
No
Yes Go to 36
What is your country of citizenship?
32
Date you became an Australian citizen
/ /
What is your current type of visa?
33
Permanent Go to next question Temporary Go to next question Unknown (e.g. arrived
on parent’s passport)
Go to 35
Are you subject to an Assurance of Support agreement?
35
Go to next question No
Yes What is the name of your Assurer?
You will need to provide proof of your Australian residence status (e.g. citizenship papers, passport or other documentation).
Go to next question
Go to 35
New Zealand passport (special category visa)
Go to 36
Except for short trips or holidays, have you EVER lived outside Australia?
36
Go to next question No
Yes If you were born outside Australia, include the country where you were born.
Include the period(s) you have lived in each country.
Do NOT include short trips or holidays.
Country of residence
1
From / / To / /
Country of residence
2
From / / To / /
If you require more space, attach a separate sheet with details.
What is your country of birth?
31
IMPORTANT
This payment can be paid for a maximum period of 13 weeks dependent on your circumstances. Before the end of the 13 weeks we will contact you to advise of the required steps that must be taken if you require further assistance. Please ensure your contact details are always up to date.
Please read this before answering the following questions.
We need to know if you have lived in any countries other than Australia from birth through to the present. ‘Lived’ means where you/your family made your home or spent a long period of time – it does not include places you visited.
29
Please read this before answering the following questions.To receive the Disaster Recovery Allowance, you must be an Australian resident living permanently in Australia.
‘Permanently’ means you normally live in Australia on a long-term basis. Holidays or short trips outside Australia would not affect this.
For more information on residency, go to www.
humanservices.gov.au/residencedescriptions
A person is not qualified for the Disaster Recovery Allowance and it is not payable if they are subject to an Assurance of Support agreement.
Child’s family name
Child’s given names
Child’s date of birth
/ /
Child’s gender
Male Female
Other name this child has been known by
Are you the principal carer of this child?
48
Give details below of your youngest dependent childIs there a shared care arrangement in relation to this child?
No Yes What is your percentage of shared care?
%
Do you have dependent children under 16 years of age in your care?
47
Go to 49 No
Yes Go to next question
Note: There are no additional payments for dependent children. If you currently receive Family Tax Benefit you may need to revise your income estimate.
Do you give permission for your partner to discuss details about your claim?
No Yes
46
Do you have a partner?
37
Go to 47 No
Yes Go to next question
Go to next question
Your partner’s Centrelink Reference Number (if known) Does your partner have a Centrelink Reference Number?
38
No Yes
Your partner’s name
Other Family name
39
First given name
Second given name
Ms Miss
Mrs Mr
Your partner’s date of birth
42
/ /
Go to next question No
Has your partner ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)?
40
Other name
Type of name (e.g. name at birth) Give details below
If your partner has more than 1 other name, attach a separate sheet with details.
Yes
Your partner’s gender
41
Male Female
Does your partner live at the same principal place of residence as you?
44
Go to next question No
Yes Go to 46
Your partner’s principal place of residence
Postcode
45
No Yes
Do you receive Family Tax Benefit for this child?
No Yes
Date you became partnered
43
/ /
EM112.151127
49
Provide details of your usual work (e.g. employment, self-employment, sub-contracting, farming).Employer’s name, business name or farm name
Australian Business Number (ABN)
Address
Postcode Phone number
( )
What industry are you employed in?
For example:
a banana industry should write: Agriculture – banana industry a clothes shop assistant should write: Retail – clothes.
Is this work
Other Give details
51
What date did you stop working or first incur a reduction in your income as a result of the disaster?/ /
52
Which one of the following reasons best describes why you have suffered a loss of income?Workplace damaged or destroyed I am unable to get to my usual workplace Cancelled bookings/orders
Cancellation of planned tourism events Loss and/or damage to stock
Injury suffered
Loss and/or damage of machinery/tools Loss of necessary utilities
Lack of staff/workers/contractors Unable to import/export products Other
53
Explain why you stopped work in further detailNote: If you did not stop working as a result of the disaster you may not be eligible for this assistance.
54
Are you on planned leave from your workplace?Go to next question No
Yes
Go to 58
55
What type of leave?For example: annual leave, sick leave, maternity.
56
Start date of leave period/ /
End date of leave period
/ /
57
Is this paid leave?No Yes Are you self-employed?
No Yes
50
Go to next question
The income you receive from self-employment must be included at question 70 and question 74.
If you have more than one employer, attach a separate sheet with details.
You must answer questions 49 to 58 for each employer.
Was your income from this employer impacted as a result of the disaster?
No Yes
Seasonal Part-time
Full-time Casual
58
Have you returned to work after the disaster?Date you returned to work after the disaster No
Yes
Go to next question
/ /
59
Do you have an income protection policy?Name of insurance company No
Yes
Go to 63
60
Have you lodged a claim or intend to lodge a claim for the loss of income?Go to 62 No
Yes
Go to next question
61
Explain why you have not lodged a claimGo to 63
62
What was the outcome of the claim?Pending decision Rejected To be lodged in future
Granted Give details below Has a waiting period been applied?
Waiting period end date No
Yes
/ /
Have payments commenced?
Attach a copy of the most recent letter or statement from the insurance policy provider showing payment details.
No Yes
63
Do you have an interest in any real estate in and/or outside Australia (other than your principal place of residence)?Go to next question No
Yes
Go to 65
64
Do you receive an income from the properties (i.e. rental/lease income)?No Yes
Go to next question
Attach a copy of your tax return for the previous year when lodging this claim.
The income you receive from rental properties must be included at question 70 and question 74.
65
Do you own any shares, options, rights, convertible notes or other securities LISTED on an Australian Stock Exchange (e.g. ASX, NSX, APX or Chi-X) or a stock exchange outside Australia?Include shares traded in exempt stock markets.
Do NOT include:
• managed investments
• investments purchased with a margin loan.
No Yes
Go to next question
Attach the latest statement for each share holding.
Name of company
1
Country if not Australia
Security code (if known)
Your share
% Number of shares or
other securities
The income you receive from these investments must be included at question 69 and question 73.
If you have more than 1 investment, attach a separate sheet with details.
Any income you receive from this insurance policy must be included at question 74.
EM112.151127
66
Do you own any shares, options or rights in PUBLIC companies NOT Listed on a stock exchange?Do NOT include:
• managed investments
• investments purchased with a margin loan.
No Yes
Go to next question
Attach the latest statement detailing your share holding for each company (if available).
Name of company
1
Current market value Number of shares, options or rights
Your share
%
Type of shares, options or rights
The income you receive from these investments must be included at question 70 and question 74.
If you have more than 1 investment, attach a separate sheet with details.
$
67
Do you have any managed investments in and/or outside Australia?No Yes
Go to next question
Attach a document which gives details (e.g. certificate with number of units or account balance) for each investment.
The income you receive from these investments must be included at question 70 and question 74.
Include:
• investment trusts
• personal investment plans
• life insurance bonds
• friendly society bonds.
Do NOT include:
• conventional life insurance policies
• investments purchased with a margin loan.
APIR code – is commonly used by fund managers to identify individual financial products.
If you have more than 1 managed investment, attach a separate sheet with details.
Name of company
1
Name of product (e.g. investment trust)
Type of product/option (e.g. balanced, growth)
APIR code (if known) Number of units
Current market value Currency if not AUD
$
Your share %
Give details below
Please read this before answering the following question.
68
An income stream product is a regular series of payments which may be made for a lifetime or a fixed period by:
• a financial institution
• a retirement savings account
• a superannuation fund
• a Self Managed Superannuation Fund (SMSF)
• a Small APRA Fund (SAF).
Types of income streams include:
• account-based pension (also known as allocated pension)
• market-linked pension (also known as term allocated pension)
• annuities
• defined benefit pension (e.g. ComSuper pension, State Super pension)
• superannuation pension (non-defined benefit).
Do you receive income from any income stream products?
Give details below No
Yes
Go to next question
Name of product provider/SMSF/SAF
1
Type of income stream
Product reference number Your share
%
You will need to obtain a schedule from your product provider for each income stream product.
The income you receive from income stream products must be included at question 66 and question 70.
If you have more than 1 income stream, attach a separate sheet with details.
Do you have any money invested in, or do you receive income from, any other investments or sources, not declared elsewhere on this form?
69
Type of investment/income
Name of organisation/company
Currency if not AUD Include:
• all investments from outside Australia (including superannuation) not declared elsewhere on this form.
Do NOT include:
• income from real estate in or outside Australia, private trusts, private companies or business
• social security payments
• an account used exclusively for funding from the National Disability Insurance Scheme.
Give details below No
Yes
Go to next question
Your share
%
1
If you have more than 1 other investment or source of income, attach a separate sheet with details.
The income you receive from these investments or sources must be included at question 70 and question 74.
You will need to provide proof of your income from other investments and sources.
EM112.151127
70
What was your gross income for the 8 weeks immediately before the disaster?Gross income is the amount of income you earn before any deductions are taken out (e.g. tax).
Include income from all sources, this includes income from employment, income protection policies, shares, investments, real estate income, superannuation, self-employment, holiday pay, commission work etc.
Source of income Amount
$
$ Total for 8 week period
$
$
Attach verification documents to confirm your income (e.g. payslips, tax returns, BAS statements or a letter from your employer).
If you have more than 7 sources of income, attach a separate sheet with details.
74
In the 14 days following your loss of income, did you receive, or are you entitled to receive, any income from any source?Source of income Amount
$
$ Total
$
$
You will need to provide proof of your income.
If you have more than 5 sources of income, attach a separate sheet with details.
Give details below No
Yes
Go to next question
$
$
$
$
71
If the disaster had not occurred, would your income have continued at the same fortnightly amount in the 13 weeks following your loss of income as it was before the disaster?Go to 74 No
Yes
Go to next question
72
Did you expect your income to:Decrease Increase
73
How much did you expect to earn each fortnight on average for the 13 weeks after the disaster?$
You will only need to provide proof of the expected increase in income (e.g. contract documents).
$
$
Tick ONE only
per fortnight
Gross income is the amount of income you earn before any deductions are taken out (e.g. tax).
Include income from employment, income protection policies, shares, investments, real estate income, superannuation, self-employment, holiday pay, commission work etc.
Do you have any accounts in banks, building societies, credit unions or church and charitable development funds?
75
Name of bank, building society or credit union
Type of account
Account number (this may not be your card number) Branch number (BSB)
Give details below No
Yes
Go to next question
Balance
$
Your share
%
1
If you have more than 2 accounts, attach a separate sheet with details.
Do you have any cash on hand?
76
No Go to next question
Name of bank, building society or credit union
Type of account
Account number (this may not be your card number) Branch number (BSB)
Balance
$
Your share
%
2
Your tax file number
77
Please read this before answering the following questions.You are not breaking the law if you do not give us your tax file number, but if you do not provide it to us, or authorise us to get it from the Australian Taxation Office, you may not be paid.
In giving us your tax file number in relation to this claim you authorise us to use your tax file number for other social security payments and services in future where necessary.
Do you want tax taken out of your payment?
No Yes
Go to next question
Amount
(must be in whole dollars)
$ .00 per payment OR
Percentage (%) of taxable payment
% per payment Enter the amount OR percentage of tax you want taken out from each payment.
Do NOT include
• an account used exclusively for funding from the National Disability Insurance Scheme
• bank accounts held in trust, or
• private companies.
Go to next question No
Not sure
Go to next question
Have you given us your tax file number before?
Go to 79 Yes
78
Do you have a tax file number?No Yes
Please call us on 180 22 66.
79
Please read this before answering the following question.Disaster Recovery Allowance is a taxable payment. If your only income for this financial year is the payment you are now claiming, you may not have to pay any tax.
However, you may have to pay tax if you get any other income this financial year, such as salary or wages.
If you think you will have to pay tax this year, you can ask us to deduct tax instalments from your payment. You can change this at any time.
If you are not sure how much tax to have taken out of your payment, contact the Australian Taxation Office.
You will need to attach proof of bank balance if your bank account balance is greater than
$38,700.
Cash on hand this refers to any cash which you have available that is not used for regular day to day expenses, such as petrol or groceries.
EM112.151127
I declare that:
• the information I have provided in this form is complete and correct.
• I have read the privacy notice above.
I understand that:
• giving false or misleading information is a serious offence.
• this payment is for people who have a loss of income as a direct result of a disaster.
• the Australian Government Department of Human Services can make relevant enquiries to make sure I receive the correct entitlement.
• the Australian Government Department of Human Services may request evidence to support any claims made on this form.
• any overpayment will be recovered.
Statement
Date
/ /
Where do you want your payment made?
80
Name of bank, building society or credit union Branch where the account is held
Account number (this may not be your card number) Branch number (BSB)
Account held in the name(s) of
The bank, building society or credit union account must be in your name. A joint account is acceptable.
Note: Payments cannot be made into an account used exclusively for funding from the National Disability Insurance Scheme.
Would you like a Centrelink social worker to contact you?
81
What number would you like to be contacted on?
No Yes
Go to next question
( )
Please tick what information has been provided with the claim.
If verification documentation is not provided with this claim it will need to be provided within 14 days.
Checklist
82
All questions on this claim have been completed Proof of identity that add up to the value of 50 points (refer to the factsheet for acceptable forms and point value of documents) Passport or visa details (if not an Australian citizen) (if you answered No at question 30)
Proof of income before the disaster (if required at question 70)
Proof of income for the 14 days following your loss of income (if you answered Yes at question 74)
84
Your signature
Copy of your tax return for the previous year (if you answered Yes at question 64) The latest statement or document for each investment (if you answered Yes at question 65, 66 or 67) A schedule from your product provider for each income stream (if you answered Yes at question 68) Proof of income from investments or other sources (if you answered Yes at question 69)
Proof of expected increased income (if required at question 73)
Privacy and your personal information
Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the
assessment and administration of payments and services. This information is required to process your application or claim.
Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law.
Relevant information may be given to Australian and State Government Departments and organisations who are involved in the joint administration of this disaster.
You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy, at www.
humanservices.gov.au/privacy or by requesting a copy from the department.
83
IMPORTANT INFORMATIONProof of bank balance (if required at question 75) Copy of the most recent letter or statement from the insurance policy (if you answered Yes at question 62)
Office Use only
SO Logon ID
Identity type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /
Identity type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /
Identity type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /
Identity type
Serial number
State of issue Country of issue
Issue date
/ /
Expiry date
/ /